CAL'FORNIA DEPARTMENT OF SOCIAL SERVICES
COMI\iIUNITY CARE LICENSiNG DIVISION
CRIMINAL RECORD STATEMENT
State taw requires that persons associated with licensed facilities be fingerprinted and disclose any conviction. A
conviction is any ptea of guilty or nolo contendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain
a copy of any criminal history you may have.
Have you ever been convicted of a crime in California ?
r]
YES
I
NO
Have you ever been convicted of a crime from another state, federal court,
military or jurisdiction outside of U.S.?
T] YES
iI
NO
Criminal convictions from another State or Federal court are considered the same as criminal
convictions in California.
lf you answer YES, give details on the back of this page indicating the nature and circumstances of
each crime and the date and the location in which each crime occurred.
You must disclose convictions, including reckless and drunk driving convictions even if:
1. lt happened a long time ago;
2. lt was only a misdemeanor;
3. You didn't have to go to court (your attorney went for you);
4. You had no jail time or the sentence was only a fine or probation;
5. You received a certificate of rehabilitation;
6. The conviction was later dismissed, set aside or the sentence was suspended.
NOTE:
IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S)THATYOU
DtD NOT DTSCLOSE ON THrS FORM, YOUR FATLURE TO DTSCLOSE THE CONVTCTTON(S) WILL
RESULT IN AN EXEMPTION DENIAL, LICENSE APPLICATION DENIAL, LICENSE REVOCATION,
OR EXCLUSION FROM A LICENSED FACILITY.
-
p"n"liy of fe4ury ,io"r tne raws of ttre si"i" ot caiiroinia that I have ,""i
and understand-the intormation contained in this affidavit and that my responses and any
! dectare under
i
; FACILIry NUMBER
FACILITY NAME
,
I
accompanying attachments are true and correct.
YOUR NAME (PRNT CLEARLY)
l
YOUR ADDRESS
ctry
l
i
SOCIAL SECURITY NUMBER
(SEE PRIVACY STATEMENT ON REVERSE SIDE)
.DATE OF BIRTH
on,tv irCer.rsE NuH,leeR
i
SIGNATURE
DATE
l
Lrc 508 (1/03i REaUTRED FORM - NO CHANGE PERMTTTED
I certify under penalty of perjury that the above information is true and correct to the best of my
knowledge.
ll.
Date
Signature
lnstructions to Licensees:
lf the person discloses a criminal conviction, review the person's statement and discuss it with your
Licensing Program Analyst (LPA). Maintain this form in your facility personnel file and send a copy
to your LPA.
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the lnformation Practices Act of 1977 (Civil Code section 1798
et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department
of Justice uses a person's SSN as an identifying number. The requested SSN is voluntary. Failure to provide the
SSN may delay the processing of this form and the criminal record check.
ln order to be licensed, work at, or be present at, a licensed facility, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522,1568.09, 1569.17 and 1596.871) The Department will
create a file concerning your criminal background check that will contain certain documents, including information that
you provide. You have the right to access certain records containing your personal information maintained by the
Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have
to provide copies of some of the records in the file to members of the public who ask for them, including newspaper
and television reporters.
NOTE: IMPORTANT INFORMATION
The Department is required to tell people who ask, including the press, if some one in a licensed facility has a
criminal record exemption. The Department must also tell people who ask, the name of a licensed facility that has a
licensee, employee, resident, or other person with a criminal record exemption.
lf you have any questions about this form, please contact your local licensing regional office.
BRIDGE,S
An Equol Opporiunity Employer
Emplovmenl Applicolion
Dote:
Lost Nome:
First
Nome:
MI:
Address:
Stote:
City:
Zip Code:
Additionol Phone #:
Phone:
Permonent Address (if different from present oddress)
No. & Street:
Stote:
City:
Zip Code:
ln cose of emergency notify
Nqme
Phone
Reloti
Employment Desired
Position opplying for:
Solory Desired:
How did you heor oboui this position?
Personol lnformolion
Hove you ever opplied to or worked for BRIDGES, lnc. before?
!
Yes
fNo
lf yes, when?
Do you hove ony friends or relotives working for BRIDGES, lnc.?
lf yes,
E Yes
ENo
stote nome(s) ond relotionships:
Nome:
Relotionship:
Nome:
Relotionship:
E yes I
lf hired, con you present evidence of your U.S. citizenship or proof of your E yes E
lf hired, would you hove o relioble meons of tronsportotion to ond from work?
No
No
legol right to live ond work in this country?
Are you oble to perform ihe essentiol functions of the job for which you ore opplying, either with or
without reosonoble
occommodotion?
E yes E
No
lf no, describe the funciions thot connot be performed.
(Note: We comply with lhe ADA ond consider reosonoble occommodolion meosures thot moy be necessory for eligible oppliconts/employees to perform
essentiol funclions. Hire moy be subjecl to possing o medicol exominolion ond to skill ond ogility tests)
Employment Appl ication
LP
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Page 1 of 5
BRIDGES
An Equol Opportunily Employer
Emplovmenl Applicolion
Educotion ond Troining
College/U niversity nome
:
No.ofYeorsCompleted:-DidyouGroduote?EvesENofDegreef]oiplomo
Whot type of degree or diplomo/Certificotion?
College/U niversity nome
:
No.ofYeorsCompleted:-DidyouGroduoteaEyesENoDDegreetroiplomo
Whot type of degree or diplomo/Certificotion?
High School nome:
Did you Groduote?
No. of Yeors Completed:
E
Yes
E ruo f,oiptomo
Vocotionol/Business School nome:
No.ofYeorsCompleted:-DidyouGroduote?f]yestrNoIcertiticoteL]other
Other Reloted Troining nome:
Did you Groduote?
No. of Yeors Completed:
E Ves I No lCertificote E Other
E
Foreign Longuoge fluency:
neod
I
write
E
speok
-
Experience
Nome of Employer:
Type of Business:
Phone Number:
Your Superyisor's Nome:
Address & Street:
City:
Dotes of Employment: From:
I
Zip Code:
Stote:
Hourly
To:
E Annuol Storting Solory:
Ending Solory:
Your Title ond Duiies:
Reoson for leoving:
Moy we contoct this employer for o reference?
E
Yes
E No
Nofe: Atfoch odditionalpogefsJ if necesso4y.
Employment Application
LP
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Page 2 of 5
BRIDGE,S
An Equol Opportunity Employer
Emplounenl Applicqlion
Experience cont.
Nome of Employer:
Type of Business:
Phone Number:
Your Superyisor's Nome:
Address & Street:
Zip Code:
Stote:
City:
Dotes of Employment: From:
E
I
Hourly
To:
Rnnuol Storting Solory:
Ending Solory:
Your Title ond Duties:
Reoson for leoving:
Moy we contoct this employer for o reference?
I
yes
E No
Nome of Employer:
Type of Business:
Phone Number:
Your Superyisor's Nome:
Address & Street:
Ciiy:
Zip Code:
Stote:
Dotes of Employment: From:
f
Hourly
To:
E Annuol Storting
Ending Solory:
Solory:
Your Title ond Duties:
Reoson for leoving:
Moy we contqct this employer for q reference?
E yes I
No
Nofe: Atloch odditionol poge/sJ if necesso4r'.
References
List
below three persons
NOT
reloied io you who hove knowledge of your work performonce within the lost three(3) yeors.
Nome:
Phone Number:
Emoil:
Address & Street:
City:
Stote:
Occupotion:
Zip Code:
No. of Yeors Acquointed:
Relotionship to you:
Employment Application
LP
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1.2
Page 3 of 5
&d
ffiEs
An Equol OPPortunitY Employer
References cont.
Phone Number:
Nome:
Emoil:
Address & Street:
Stote:
City:
ZiP
Code:
No. of Yeors Acquointed:
Occupotion:
RelotionshiP to You:
Phone Number:
Nome:
Address & Street:
Emoil:
Stote:
City:
ZiP
Code:
No. of Yeors Acquointed:
Occupotion:
RelotionshiP to You:
Employment Applicatio n
LP
IM
All
12
Page 4 of 5
RIDGtrS
An Equol Opportunity EmPloYer
Emplovment Applicoiion
Pleose Reod Corefully, lnitiql Eoch Porqgroph ond Sign Below
I
hereby certify thot I hove not knowingly withheld ony informotion thot might odversely
offect my chonces for employment ond thot the onswers given by me ore true ond correct to the
best of my knowledge. I further certify thot l, the undersigned opplicont, hove personolly completed
this opplicotion. I understond thot ony omission or misstotement of moteriol
foct on this opplicotion or
on ony document used to secure employment sholl be grounds for rejection of this opplicotion or for
immediote dischorge if I om employed, regordless of ihe iime elopsed before discovery.
I
hereby outhorize
BRIDGES,
lnc. to thoroughly investigote my references, work record,
educotion ond other motiers reloted to my suitobility for employment ond, further, outhorize the
references I hove listed to disclose to the compony ony ond oll letters, reports ond other informotion
reloted to my work records, without giving me prior notice of such disclosure. ln oddition, I hereby
releose the Compony, my former employers ond oll other persons, corporotions, portnerships ond
ossocioiions from ony ond oll cloims, demonds or liobilities orising out of or in ony woy reloted to such
invesiigotion or disclosure.
I
understond thot nothing contoined in ihe opplicotion, or conveyed during ony
interview which moy be gronied or during my employment, if hired,
is
intended to creofe on
employment controct between me ond the Compony. ln qddition, I understond ond ogree thot if
om employed, my employment
is
I
for no definite or determinoble period ond moy be terminoied ot
ony time. with or without prior notice, of the option of either myself or the Compony, ond thot no
promises or representotions controry to the foregoing ore binding on the compony unless mode in
writing ond signed by me ond the Compony's designoied representotive.
Appliconf Signoture:
Employment Application
Dote:
LP
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Page 5 of 5